Dear Ethix – Issue 57

Alternate Dispute Resolution

The Conversation with Ken Melrose on the alternate dispute resolution (ADR) raised the question of its application to hospitals and health care.

Yes, there is application. Where there is a clear action/outcome such as the mistaken administration of a medication, wrong test, wrong surgery, I am sure this approach is applicable and in some cases employed by this industry.

In many health care instances the action/outcome is not as clear cut as the Toro injury case. Numerous variables can intervene in the human biological system, many known but some not known to medicine. Examples include a poor patient outcome due to the failure of the human body to respond in the normal and expected way, e.g., an infection following surgery, or a rare immune response to a common medication or treatment.

Another overlay in health care is the patient’s expectation. With all the advances in medicine, patients sometimes have an unrealistic expectation that anything can be fixed, e.g., reattaching a finger amputated by a lawnmower and not regaining 100 percent function. Or patients misunderstand that a 1 percent chance of a bad event still means that, on average, one in 100 patients will experience this adverse event and for that individual his experience is not a probability but a reality.

For all of our advances, health care is still a combination of science and art. Some would like to reduce medicine to the Toyota lean-manufacturing methodology. This has its place in reducing variation and improving health care processes. It doesn’t address the variable response of the human body to diagnostic and therapeutic interventions.

Despite medical advances, medicine is by and large conservative, resists change, and mistrusts the legal system. To the extent that ADR can expand into health care will take efforts of all three parties, patients, doctors, and attorneys.

Here is an example of why health care mistrusts the legal system. You may have seen the advertisements on TV recently by attorneys encouraging patients to call them who have developed NSF, nephrogenic systemic fibrosis. Why? NSF is a rare complication recently described and linked to the administration of gadolinium contrast when performing MRI exams in order to improve the quality of the scan. Patients most at risk appear to be those with decreased kidney function. As of September 2007, approximately 250 cases had been reported worldwide. Millions of doses of gadolinium have been administered over the years that MRI has been used for diagnosis. If medicine responds from a defensive posture, almost every patient receiving gadolinium would be screened with a blood test (cost, inconvenience, and pain) in order to prevent this happening to a very small number of patients. Practicing in this fashion in order to avoid rare and potentially costly outcomes and resulting litigation would be a cost all of us will bear. Health care is complex, relies on a predictable response from a very complex system (our bodies), and therefore is not 100 percent safe. How do we balance the costs and needs of the individual with that of our society? Perhaps ADR can help.

Douglas L. Gibson
Former Hospital Executive, Currently President and CEO of a Medical Services Company
Bellevue, Wash.

Subprime Loans

Your article about “What Happened to the Housing Market” was helpful with understanding “subprime” mortgages. I don’t feel so ignorant when I learn that Greenspan also was unaware of the problem with subprime lending until late 2005.

Much has surfaced recently about Merrell Lynch and Citigroup [and UBS] months after the Countrywide fiasco was supposed to be over. If the heads of Enron were being prosecuted for illegal fraud, why should these other guys get off with mega-millions? Where is the fairness? Where is the compensation for our stock-market losses when the information was closely held?

John N. Johnson
Redmond, Wash.

Walden Media

I loved the Conversation with Micheal Flaherty. Thanks for making movies that all of my family can enjoy together. We particularly enjoyed Holes. Keep the family movies coming, and don’t stop!

William Hopson
Fresno, Calif.

I particularly enjoyed this issue of Ethix. Michael Flaherty talks about the complementary but very different experiences of a movie and a book by the same title. I recently discovered when I got my iPod hooked into the car stereo that talking books are yet another sensory way to assimilate and enjoy books; I find the experience to be totally different from reading the book. You can’t skim when listening. I have listened to some of my childhood favorites by Jules Verne, and I found that 20,000 Leagues Under the Sea was actually not just an adventure novel, it was a technological tour de force about electricity, a thorough lesson in undersea biology and geography, and a brief on the cultural collisions of the time. The sequel The Mysterious Island was a better- than-Boy-Scout treatise on survival and ingenuity; the fact that the hero was an engineer who knew all and could do everything with meager tools also felt good!

Beyond Walden Media, I was surprised that you were able to put together such a good piece on the housing crash while it is still coming apart. Nice work!

Peter Morton
Whidbey Island, Wash.